Turnbull’s hospital pass

Prime Minister Malcolm Turnbull has indicated financial relief for the nation’s beleaguered public hospitals will depend on finding additional sources of revenue, delivering a blow to hopes of averting a multi-billion dollar funding crisis set to hit the system from next year.

Mr Turnbull told a meeting of the AMA Federal Council that hospital funding was “a big issue”, and he fuelled speculation of a pre-election spending boost after revealing he was “in discussions” with premiers and chief ministers on the matter.

But the Prime Minister gave no sign his Government was contemplating a major change in the policy course set by the Coalition in 2014 when it announced funding changes that would rip $57 billion out of the public hospital system between 2017 and 2025.

Instead, he reinforced the need for more effective health spending, signalling there would be no let-up in the pressure on doctors, nurses and other health professionals to deliver greater efficiencies.

“Hospital funding is a big issue,” Mr Turnbull said. “It is something I am in discussions with chief ministers and state premiers [about], and we have COAG before not very long, where we will seek to take that issue forward.”

“[But], the big issue is where additional funding will come from.”

Several premiers, most notably Mike Baird in NSW and Jay Weatherill in South Australia, had proposed an increase in the GST – partially offset by other tax changes – to increase the health budget, but the Prime Minister reiterated his Government would not contemplate an increase in tax revenue.

“We have to recognise that Australians already pay high taxes,” Mr Turnbull said. “This is not a low-tax country, so getting better value [for health spending] is vital.”

Instead, while praising advances in the quality and effectiveness of health care, he exhorted health service providers to greater efficiency.

The Prime Minister said rising health expenditure was “often seen as an admission of failure, [but] the reality is that we are getting a lot more for it”, in terms of longer and healthier lives.

However, funding constraints meant that “the pressure is to get better and more effective outcomes” for the same outlay.

Q&A at AMA House

Following one-on-one talks with AMA President Professor Brian Owler, Mr Turnbull was joined by Health Minister Sussan Ley in meeting with AMA Federal Councillors, who grilled the pair on significant aspects of Federal Government health policy including public hospital funding, the Medicare rebate freeze, pathology and diagnostic imaging bulk billing incentives, medical workforce training and emergency department performance targets.

Several AMA Federal Councillors including Dr Tim Greenaway, Dr Saxon Smith and Dr David Mountain challenged the PM and Health Minister on the scale of the Federal Government’s cuts to hospital funding, pointing out the sharp growth in demand for hospital services occurring around the country.

Mr Turnbull questioned why there was a sharp rise in the number of patients showing up at hospital emergency departments, speculating that some of it may be due to a failure in primary care.

But Dr Mountain and Dr Smith explained that as people lived longer, they developed multiple health problems that could compound one another and quickly escalate, requiring expensive and complex emergency care.

Questioned on the Medicare rebate freeze, Ms Ley said on-going Budget deficits meant the Government was not in a position to restore rebate indexation, and was instead examining new models of primary care arising out of the recent review.

Addressing the cut to bulk billing incentives, the Health Minister said it was “not healthy” that the pathology sector was dominated by two providers, and said the major issue raised by pathologists she consulted with was not the incentive cut, but rents charged to co-locate with medical practices.

Ms Ley added that bulk billing incentives for concession card radiology patients had not been touched, supporting their access to care.

On medical training, Ms Ley said she was concerned to find ways to get more “generalist” practitioners into rural areas. The Minister said she did not believe in using Medicare provider numbers and other methods to bond doctors to work in particular areas, but the problem of luring more doctors into rural practice was one that “we do have to collectively solve”.

The Minister said the Government understood concerns around the establishment of a third medical school in Perth, but expressed doubts that the decision could be “unravelled”.

Adrian Rollins

Necrotising myositis presenting as multiple limb myalgia

Clinical record

A previously healthy 40-year-old man was referred by his general practitioner to our hospital after a short prodromal period of a sore throat and rapidly deteriorating constitutional symptoms. Most pertinent to his diagnosis was the development of non-traumatic, localised, right calf pain 48 hours before admission that progressed to an inability to bear weight by the time of hospital presentation. On initial physical examination, he had a temperature of 37.8°C, diffuse muscle tenderness in all four limbs and an exquisitely hyperalgesic localised area on the right mid-calf. Examination of his throat showed a diffuse pharyngitis. There was no rash or arthritis, and his cardiovascular, respiratory and gastrointestinal systems were all unremarkable at admission.

A blood sample and throat swab were taken and, after an initial blood and microbiological culture work-up, empirical treatment with intravenous flucloxacillin and vancomycin was commenced. Early pathology test results showed a creatine kinase (CK) level of 380 U/L (reference interval [RI], < 171 U/L), serum creatinine level of 158 μmol/L (RI, 55–105 μmol/L), white cell count of 3.1 × 10⁹/L (RI, 4.0–11.0 × 10⁹/L) with increased band forms, and deranged liver function test results, with a bilirubin level of 60 μmol/L (RI, < 20 μmol/L) and alanine transaminase level of 242 U/L (RI, 0–45 U/L).

Over the next 24 hours, the patient’s condition deteriorated, prompting consultation with an infectious diseases specialist. This resulted in a change of antibiotic therapy to ceftriaxone to broaden the coverage of respiratory pathogens, given his acute pharyngitis, and clindamycin to restrict any potential toxin production. By the evening of the second hospital day, the patient was referred to the intensive care unit (ICU) with evolving multiple organ failure. He was now febrile to a temperature of 40°C, with evolving septic shock, pulmonary infiltrates, worsening acute kidney injury (serum creatinine level, 201 μmol/L, and oliguria) and mild delirium. His right calf remained a focal point of concern, with an accompanying tenfold rise in CK level to 3656 U/L.

The patient’s condition further deteriorated during his first night in the ICU, necessitating aggressive fluid resuscitation, vasopressor support and haemodialysis. By the morning of the third day in hospital, 12 hours after ICU admission, an isolated, small, tender area of discolouration was noted over the distal posteromedial aspect of the right leg, with no other clinically apparent lesions, but persisting myalgia in all four limbs. This, in conjunction with the confirmation of gram-positive cocci grown from the admission blood and throat swab cultures, prompted the initial consideration of necrotising fasciitis. Subsequent imaging of the lower limbs with ultrasound and non-contrast computed tomography (CT) scans excluded venous thrombosis and fascial thickening, but both tests showed subtle swelling of the calf muscles, suggesting myositis (Figure, A). An urgent plastic surgery consultation mandated surgical exploration of the right calf, and the diagnosis of necrotising myositis (NM) (Figure, B) was subsequently obtained.

Due to the ongoing requirement for frequent soft tissue debridement, the patient was ventilated and transferred to the nearest quaternary hospital. Here, he underwent further imaging of all four limbs and successive debridement of his right leg and both arms for NM on Days 4, 5, 7, 9 and 18 of admission. After receiving confirmation of susceptibility, the ceftriaxone was changed to benzylpenicillin, while clindamycin was retained and intravenous immunoglobulin (IVIG) commenced. Microbiological serotyping confirmed Streptococcus pyogenes with type emm 89.0 strain; exotoxin assays were not conducted. The patient’s total ICU stay lasted 17 days, with liberation from haemodialysis after 7 days and the ventilator after 9 days, resolution of his multiple organ failure, and all four limbs preserved without amputation. After 33 days in hospital, he was discharged to a rehabilitation centre.

Necrotising myositis is a rare but potentially fatal form of infection, predominantly characterised by muscle necrosis capable of rapidly progressing to multiple organ failure in healthy young adults. Published literature attributes group A streptococcus as the most commonly implicated pathogen, but NM has also been associated with groups C and G streptococci, Bacteroides subtilis, Staphylococcus aureus and Peptostreptococcus.1,2

Our case highlights three important clinical lessons. First, NM typically involves a single limb or area. Multiple limb involvement in the initial presentation has only been reported in two previous cases.3,4 Second, despite the widespread limb involvement in our patient, skin discolouration was a subtle, late sign. It presented in only one limb 72 hours after symptom onset, at a stage when the toxic shock syndrome was already apparent. Of 14 previously reported cases, only five describe skin discolouration and two describe local erythema.1,3–8 Third, and most crucially, NM, like necrotising fasciitis, remains a clinical diagnosis, with most investigations being indeterminate.

Increased serum CK level has previously been lauded as a potential early warning sign,4–6 but the initial CK result at our patient’s hospital admission (already more than 48 hours after the onset of symptoms) was only marginally raised (380 U/L). We found two other previously reported cases of NM where the CK level remained below 500 U/L at 48–72 hours after symptom onset.6,7 These findings suggest that excluding NM on the basis of small rises in serum CK level (< 500 U/L) is unreliable. Similarly, a reliance on imaging to provide a diagnosis can result in non-specific or negative findings, delaying a definitive surgical diagnosis and treatment.8 While modern imaging can be performed rapidly, the CT and ultrasound scan findings in our patient were subtle, non-specific and ultimately delayed surgery by 3–4 hours.

Once a diagnosis of NM is suspected, aggressive surgical debridement, appropriate antibiotic therapy and supportive care are mandated for survival. Early surgical intervention has reduced mortality from 100% to 37%,1 but with the consequence of significant long-term morbidity for many survivors. Aggressive group A streptococcal infections respond less well to penicillin and continue to be associated with high mortality and extensive morbidity, leading to the use of adjunctive therapies.9 In a recent observational Australian study of 84 patients with severe invasive group A streptococcal infection, the addition of clindamycin resulted in a significant reduction in mortality, which was further enhanced by the inclusion of IVIG.10 Clindamycin inhibits bacterial protein synthesis at the level of the 50S ribosome, resulting in decreased exotoxin production and increased microbial opsonisation and phagocytosis, while IVIG increases the ability of plasma to neutralise superantigens.9,10 Finally, conclusive evidence is lacking for the use of hyperbaric oxygenation, aimed at reducing hypoxic leucocyte dysfunction, and it was not used for this patient.

Lessons from practice

Necrotising myositis is a rare but potentially fatal condition. It is a diagnostic conundrum, often presenting as systemic toxicity and widespread myalgia without focal features.
Improved survival is underpinned by early clinical diagnosis, appropriate antibiotic therapy including clindamycin to reduce exotoxin load, and urgent surgical referral. Adjunctive therapies such as intravenous immunoglobulin and hyperbaric oxygenation should be considered based on individual circumstances.
Previously suggested diagnostic investigations such as serum creatine kinase levels, ultrasound and computed tomography scans are unreliable, mandating a high index of clinical suspicion to make a diagnosis.

Figure

A: Computed tomography scan (transverse plane) of the right leg, showing subtle hypointense and mildly expanded gastrocnemius and soleus muscles with intact fascia, suggestive of myositis. B: Haematoxylin and eosin stained paraffin section of the right gastrocnemius muscle, showing necrotic skeletal muscle, inflammatory infiltrate with disintegrating neutrophils and colonies of streptococcal bacteria.

[Seminar] Clonorchiasis

On Aug 21, 1875, James McConnell published in The Lancet his findings from a post-mortem examination of a 20-year-old Chinese man—undertaken at the Medical College Hospital in Calcutta, India—in whom he found Clonorchis sinensis in the bile ducts. Now, exactly 140 years later, we have a sound understanding of the lifecycle of this liver fluke, including key clinical, diagnostic, and epidemiological features. Developments in the so-called -omics sciences have not only advanced our knowledge of the biology and pathology of the parasite, but also led to the discovery of new diagnostic, drug, and vaccine targets.

AMA in the News – 23 February 2016

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

AMA attacks health insurers’ clawback, Adelaide Advertiser, 5 February 2015
Private health insurance customers could finally see a slowdown in the rate of premium rises, amid criticism of insurers for scaling back members’ entitlements. AMA President Professor Brian Owler accused some insurers of scaling back members’ coverage.

Sticking up for all children, Northern Territory News, 8 February 2016
The AMA wants all children who fall behind on their vaccination program to be allowed to catch up for free, calling for further Federal Government funding to boost immunisation rates. AMA President Professor Brian Owler said Government claims that health spending was unsustainable were not backed by evidence.

Medicare plan risks privacy, Adelaide Advertiser, 12 February 2016
A private company would know whether a patient had an abortion, herpes or was getting mental health treatment if the Government proceeds with a plan to privatise Medicare and medicine payments. The AMA is calling on the Government to change the system so a patient’s Medicare rebate could be assigned directly to the doctor.

Anti-vax nuts crack at last, The Sunday Telegraph, 14 Februay 2016
Almost 260 extra children are being immunised every week as even the most hardened anti-vaccine fanatics change their view. AMA President Professor Brian Owler said people are starting to realise the anti-vaccination lobby does not hold weight, and some of the policies are starting to take effect.

Indigenous health vital, The Herald Sun, 18 February 2016
AMA President Professor Brian Owler, in Alice Springs visiting health groups and clinics, said the Closing the Gap report, released last week, indicated that health had fallen off the radar.

Bulk-billing on the rise despite mooted cuts, The Australian, 19 February 2016
Bulk billing rates have continued to rise despite health groups warning patients will be left out-of-pocket because of a Federal Government freeze on Medicare rebates. AMA President Professor Brian Owler said the plan to remove the bulk billing incentive from pathology services was a sign the co-payment had risen from the grave.

Radio

Professor Brian Owler, 666 ABC Canberra, 8 February 2015
AMA President Professor Brian Owler discussed the AMA’s Pre-Budget Submission. Professor Owler criticised the Federal Government for telling basic ‘untruths’ about health spending.

Dr Brian Morton, 2GB Sydney, 9 February 2016
AMA Chair of General Practice Dr Brian Morton discussed homeopathy. Dr Morton said he was concerned that people who chose homoeopathy might put their health at risk.

Professor Brian Owler, ABC News Radio, 11 February 2015
AMA President Professor Brian Owler talked about health spending and the MBS Review.

Professor Brian Owler, ABC South East NSW, 15 February 2016
AMA President Professor Brian Owler discussed hydrocephalus. Professor Owler said shunt registry for hydrocephalus could be used as a quality assurance tool in order to decrease blockages and infections which affect morbidity and increase costs to the health system.

Television

Professor Brian Owler, ABC News 24, 28 December 2015
Landmark legislation will be introduced into Parliament to legalise medicinal cannabis. AMA President Professor Brian Owler said medicinal cannabis should be regulated in the same way as other narcotics.

Professor Brian Owler, CNN, 16 February 2016
AMA President Professor Brian Owler slammed Government policy on asylum seekers. Professor Owler said doctors who work with asylum seeker children face an incredible ethical dilemma, because they cannot allow children to be discharged into an unsafe environment.

Professor Brian Owler, SBS Sydney, 17 February 2016
Prime Minister Malcolm Turnbull said there would be no change to Australia’s border protection policies despite an offer from New Zealand Prime Minister John Key to take in children headed for offshore detention. AMA President Professor Brian Owler said this was a complex issue, but the issue facing the AMA is to ensure the health care of asylum seekers and getting children out of detention.

Govt actions unhelpful, MBS Review head admits

The hand-picked head of the Commonwealth’s Medicare Benefits Schedule Review has taken a veiled swipe at the Government over its handling of plans to axe 23 MBS items.

Confirming medical profession fears about the potential politicisation of the process, Professor Bruce Robinson told an AMA-hosted forum on the MBS Review that the taskforce co-ordinating the review had been given no say over a 28 December announcement by Health Minister Sussan Ley that an initial batch of 23 items had been recommended for removal from the MBS.

Professor Robinson told the forum, which was attended by representatives from almost 50 specialist colleges and societies, that the announcement was “something we did not have control over”.

In her announcement, Ms Ley said the items were obsolete and no longer consistent with clinical best-practice. The Government suggested axing them would save around $6.8 million a year.

But Professor Robinson cast doubt on the scale of savings from the measure, and lamented that the Government’s handling of the issue had tarnished medical profession support for the MBS review.

“The announcement was unfortunate, because it is one of those things that has caused criticism of the review process,” Professor Robinson said, adding that “those items to be deleted are not going to save much money; it’s a tidying up exercise.”

AMA President Professor Brian Owler told the forum, the second organised by the AMA, that the medical profession had taken part in the review with enthusiasm and goodwill, but that had been put at risk by the Minister’s post-Christmas announcement, as well as the Government’s unilateral action to unveil cuts to bulk billing incentives for pathology and diagnostic imaging services in the Mid-Year Economic and Fiscal Outlook (MYEFO).

“There’s a lot of goodwill within the medical profession to work with Professor Robinson and the Taskforce to improve the MBS. We all want a more modern MBS that reflects modern medical practice that is going to benefit patients,” Professor Owler said. “[But] if you engage the profession on that basis and then come out with an announcement in MYEFO, without any consultation or discussions…of course people are going to be upset.”

Dr Michael Harrison, from the Royal College of Pathologists of Australia, told Professor Robinson that the Government’s decision to axe bulk billing incentives for pathology services, taken without consultation, had “undermined the credibility of the [MBS] review”.

“Our confidence in the review has been severely affected,” he warned.

Much of the medical profession’s concern about the Medicare review has centred on doubts about its over-riding purpose.

Professor Robinson told the forum the focus was to modernise the MBS and align it with current clinical practice.

“My task is not to save money”, Professor Robinson said, and added that the taskforce did not have a savings target.

But the Government is intent on using the exercise to achieve savings, much of which will be used to help cut the Budget deficit. Ms Ley has indicated only half of any funds freed up as a result of the review will be re-invested in health.

Professor Owler acknowledged the review was like to deliver some savings (though probably not as many as the Government hoped), but warned the profession’s goodwill and support was contingent on any savings made were “held within health, to provide better services to patients”.

Adrian Rollins

Latest news:

Privacy risk on Medicare outsourcing

The AMA has raised concerns that any move to outsourcing Medicare payments to the private sector could compromise patient privacy and further fragment their care.

Prime Minister Malcolm Turnbull has confirmed an overhaul of the Medicare payments system is under active consideration, with Health Minister Sussan Ley revealing the Health Department is investigating ways to digitise “transaction technology for payments”.

Though the Government has not explicitly said it is looking at outsourcing the payments system to the private sector, the AMA said such a move would be in keeping with the Commonwealth’s broader policy agenda to increasingly offload responsibility for funding and providing health care.

According to a report in the West Australian newspaper, the Government is well advanced in plans to outsource the processing of Medicare, Pharmaceutical Benefits Scheme and aged care claims and payments, as well as the administration of eligibility criteria.

The newspaper reported that the change was likely to be unveiled in the forthcoming Budget, with a call for tenders issued soon after.

It has been suggested that Australia Post, Telstra and the big banks, as well as overseas firms including Serco, Fuji-Xerox and Accenture, may bid for the work.

AMA Vice President Dr Stephen Parnis said such a move would raise serious privacy issues.

“There are concerns raised about the way that the administrators of these programs would handle confidential medical data; how their input may influence or undermine the doctor-patient relationship in terms of its funding,” Dr Parnis told ABC Radio.

He said it raised the prospect that a Medicare benefit item “might be administered, or potentially even refused, by someone who isn’t necessarily accountable to Government”.

The outsourcing idea is the latest move by the Federal Government to change Medicare, after its failed attempts to introduce a GP co-payment, the institution of a four-year rebate freeze, a review of the Medicare Benefits Schedule, and cuts to bulk billing incentives for pathology and diagnostic imaging services.

But Mr Turnbull insisted that Government was “totally committed” to Medicare, and any change to its payments system was aimed at improving the service for consumers.

“What we are looking at, as we look at in every area, is improving the delivery of Government services, looking at ways to take the health and aged-care payment system into the 21st century,” the Prime Minister told Parliament. “This is about making it simpler and faster for patients to be able to transact with Medicare to get the services they are entitled to.”

Ms Ley said that “every day, Australians use cards to make ‘tap and go’ payments, and apps to make payments, and yet Medicare has not kept up with these new technologies”.

She said the Health Department was working with “business innovation and technology experts to determine the best and most up-to-date payment technologies available on the market for consumers and health and aged care service providers”.

The infrastructure of Medicare’s payments system is more than 30 years old, and although it processes more than 370 million patient rebates each year, the system’s age means it is becoming harder to add new types of payments.

The Opposition has slammed the outsourcing proposal, characterising it as an attempt to privatise Medicare, and there are concerns the policy would cause more than 1400 Department of Human Services workers involved in processing and payments to lose their jobs.

Adrian Rollins

New prostate cancer clinical guidelines launched

Australian health professionals will now have access to evidence-based recommendations for using the prostate specific antigen (PSA) blood test to assess prostate cancer risk in patients.

The PSA Testing and Early Management of Test-detected Prostate Cancer: Guidelines for health professionals were developed in partnership with the Prostate Cancer Foundation of Australia (PCFA) and Cancer Council Australia and have now been approved by the National Health and Medical Research Council (NHMRC).

PCFA Chief Executive Officer, Associate Professor Anthony Lowe said contention about the PSA test has made it difficult for health professionals to take a consistent, evidence based approach to the test.

“The guidelines cut through the contention and provide guidance in relation to an individual man’s circumstances and on how to manage a patient if he requests and consents to taking the test,” he said.

The recommendations include:

Men considering a PSA should be given information about the benefits and harms of testing.
Men with an average risk who have decided to undergo regular testing after being informed of the benefits and harms should be offered PSA testing every 2 years from age 50-69. If the total PSA concentration is greater than 3ng/mL then further investigation should be offered.
Men over 70 who have been informed of the benefits and harms of testing and who wish to start or continue regular testing should be informed that the harms of PSA testing may be greater than the benefits of testing in their age group.
Men with a father or one brother who has been diagnosed with prostate cancer has 2.5 – 3 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 45 to 69.
Men with a father and two or more brothers who have been diagnosed with prostate cancer have at least 9 to 10 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 40 to 69.
In a primary care setting, digital rectal examination is not recommended for asymptomatic men in addition to PSA testing however this may be an important assessment procedure if referred to a urologist or other specialist for further investigation.
Mortality benefit due to an early diagnosis of prostate cancer due to PSA testing isn’t seen within less than 6-7 years of testing so PSA testing isn’t recommended for men who are unlikely to live another 7 years (subject to health status).
A PSA testing decision aid for men and their doctors is under development by PCFA and Cancer Council Australia.

Other recommendations also include further investigations if the PSA concentration is above 3 ng/mL; prostate biopsy and multiparametric MRI; active surveillance and watchful waiting.

The report says there is no evidence to support a national PSA screening program to all men of a certain age group.

Cancer Council Australia CEO, Professor Sanchia Aranda says use of the guidelines will hopefully reduce the level of over-treatment.

“The NHMRC’s Information Document for health professionals, recommended as a companion document to the guidelines, estimates that for every 1000 men aged 60 with no first degree relatives affected by prostate cancer who take the test annually for ten years, two will avoid a prostate cancer death before the age of 85 as a result. Yet 87 men will receive a false-positive PSA test result and have an invasive biopsy that they didn’t require –28 will experience side-effects, including impotence and incontinence, as a result of this biopsy, and one will require hospitalisation.”

PSA Testing and Early Management of Test-detected Prostate Cancer: A guideline for health professionals is available for download at www.pcfa.org.au and wiki.cancer.org.au/PSAguidelines.

Latest news:

Patients face $100 x-rays

The Federal Government is coming under pressure over concerns its cuts to bulk billing incentives will leave patients needing x-rays, ultrasounds, MRIs and other diagnostic imaging services hundreds of dollars out-of-pocket.

Estimates by the Australian Diagnostic Imaging Association (ADIA) suggest general patients who are currently bulk billed will face significant up-front costs, from up to $101 for an x-ray to as much as $532 for an MRI, if the Government’s plan to wind back bulk billing incentives for diagnostic imaging and axe them for pathology services is approved.

When the changes were unveiled in the Mid-Year Economic and Fiscal Outlook in December, AMA President Professor Brian Owler condemned them as “a co-payment by stealth”.

“Cutting Medicare patient rebates for important pathology and imaging services is another example of putting the Budget bottom line ahead of good health policy,” Professor Owler said. “These services are critical to early diagnosis and management of health conditions to allow people to remain productive in their jobs for the good of the economy.”

His concerns have been borne out by the ADIA’s analysis, which shows the Medicare rebate for an x-ray will be cut by $6 under the changes, while the rebate for an ultrasound will be $12 less, that for a CT scan will be $34 lower, $43 less for a nuclear medicine service and $62 less for an MRI.

The Association said the effect of these cuts would be amplified by the fact that, under Medicare, patients have to pay the full cost of the service upfront before being able to claim the rebate.

In practice, this will mean that a general patient having an x-ray will be required to pay between $54 and $101 before being be able to claim their Medicare rebate.

Patients requiring an MRI will face the biggest upfront charge, ranging from $422 to $532.

Even after receiving their rebate, patients will still be left out-of-pocket. The ADIA calculates that for an x-ray, patients will ultimately lose between $6 and $56, while those needing an MRI will take a financial hit of between $62 and $173.

General patient diagnostic imaging expenses as a result of bulk billing incentive cuts

	X-ray	Ultrasound	CT scan	Nuclear Medicine	MRI
Rebate cut	$6	$12	$34	$43	$62
Upfront costs	$54-101	$117-206	$323-434	$407-463	$422-532
Out-of-pocket costs	$6-56	$12-101	$34-145	$43-99	$62-173

Source: Australian Diagnostic Imaging Association

ADIA President Dr Christian Wriedt said the changes were introduced without consultation and, by potentially deterring people from seeking early diagnosis and treatment, represented “bad policy”.

“This will make it much more difficult for many patients to receive the life-saving level of care they need,” Dr Wriedt said. “We are talking about services that are absolutely essential to diagnosing and treating many conditions, and we’re making it harder for people to get. More people, especially those with chronic, serious conditions, will not be properly assessed.”

Shadow Health Minister Catherine King said patients with serious, ongoing conditions such as cancer and heart complaints would be hardest hit.

“Patients with serious conditions never need just one scan,” Ms King said, citing the example of someone with thyroid cancer.

She said a confirmed diagnosis involved having an ultrasound and thyroid function test, a follow-up ultrasound and pathology tests, and a final round of head or body scans.

“All up, that comes to around $1000 in upfront charges,” Ms King. “Patients will eventually get much of this back from Medicare, but they will still be left with hundreds of dollars in out-of-pocket expenses.”

Health Minister Sussan Ley has so far pushed back against such concerns, pointing out that the Government has not touched Medicare rebates and arguing that bulk billing incentives – introduced by Labor in 2009 – were an unjustified handout to providers.

But Dr Wriedt said Medicare rebates for diagnostic imaging services had not been indexed for 17 years, ratcheting up the financial pressure on providers and leaving them with little choice but to pass the bulk billing incentive cuts through to patients.

He said the Government’s strategy was to push more costs on to consumers.

“Let’s not kid ourselves. This is a cash grab and a co-payment by stealth,” he said. “They [the Government] know that this will hurt people, and particularly the most vulnerable in our communities, and yet they’re pushing ahead.”

But the Government’s plan might yet fall afoul of the Senate, where it will have to rely on the support of cross-bench senators to get the measure passed.

At least one has flagged she will join Labor in opposing the changes.

Independent Tasmanian Senator Jacqui Lambie has threatened to vote against all Government legislation in order to prevent cuts to bulk billing incentives for pathology and diagnostic imaging services.

Realisation that the cuts could result in women being charged for pap smear tests provoked widespread outrage, and almost 190,000 have signed a Change.org petition protesting the measure.

Senator Lambie said it was time the Government stopped its “sneaky attacks on Medicare”.

“Australian women should not have to pay more for vital cancer health checks,” she said. “Over my dead body will I allow the Liberals to try and sneak through more changes and cuts to our Medicare system. I will vote to block all their legislation in the Senate until they stop playing with our Medicare system.”

Adrian Rollins

Pap smear scare a warning

As the Federal Government embarks on an election year, Health Minister Sussan Ley has had a sobering lesson in the power of social media.

When a story was posted on website Mamamia early on 6 January claiming women would be charged $30 for a pap smear because of the Federal Government’s cuts to pathology and diagnostic imaging bulk billing incentives, it sparked a storm of protest.

A petition on change.org protesting the cuts rapidly gained momentum. By late that morning, it had garnered more than 10,000 signatures.

It was not until almost midday that Ms Ley responded, going on Twitter to argue that there had been “no cut 2 $ value of Medicare Rebate YOU receive 4 pap smear/test or your access to it as falsely claimed 2day”.

But by then the horse had well and truly bolted.

The message that women would for the first time likely to be charged out-of-pocket expenses for a pap smear had spread far and wide through Twitter, Facebook, and other social media, and was being picked up by mainstream news outlets.

As the day wore on, the Minster posted more tweets trying to calm the storm, and her office issued a statement attacking what it said were misleading claims.

In it, her spokesperson said there had been no shift in the cost of having a pap smear or the Medicare rebate.

The sole change, the spokesperson said, was to scrap the incentive paid directly to pathology providers, worth between $1.40 and $3.40 for each pap smear.

“It is therefore not part of the patient’s Medicare rebate, as some have tried to claim,” the spokesperson said, and Ms Ley has insisted that competitive pressures in the pathology industry mean providers will have to absorb the cost rather than pass it on to patients – an assertion the sector disputes.

The Government has struggled to gain traction on the issue.

Its complex and nuanced argument has been drowned out by the simple message being broadcast far and wide on social media that women will be charged for a pap smear.

The scale of the Government’s problem has been laid bare by the fact that, despite numerous media interviews and statements rebutting the $30 pap smear claim, by mid-Friday the petition was closing in on 200,000 signatures.

The episode is a salutary lesson for the Minister and the Government in the perils of blindsiding health groups and the public with unheralded cuts and changes.

There was no consultation prior to the announcement in the Mid Year Economic and Fiscal Outlook on 15 December of $650 million cuts to the bulk billing incentive for pathology and diagnostic imaging services, and little subsequent detail about the measure, leaving a virtual vacuum in which confusion and apprehension could quickly develop.

In the febrile atmosphere of a Federal Election, where the pressure for instant judgement calls and responses is intense, issues can quickly spiral out of any political control.

It could be a very long year for the Government unless it changes tack on how it does business.

Adrian Rollins

Govt faces storm over cuts to pap smear payments

Women face being charged to get their pap smear results under Federal Government plans to axe bulk billing incentives for pathology services.

Calculations by the AMA show the Government’s contribution to the cost of a pap smear will be cut by 12 per cent to $23.55 from 1 July, a $3.20 reduction. There were almost 1.8 million pap smears conducted in 2014-15, suggesting the cut will save the Government around $5.7 million a year.

Pathology providers, who have had no increase in the Medicare rebate for their services for almost two decades, have warned that many labs will not be able to absorb the cut and will instead have to pass it on to their patients.

The amount charged to patients is likely to increase above $3.20 to account for the additional administrative costs of billing individuals, including processing payments and chasing up amounts owing.

Royal College of Pathologists of Australasia Chief Executive Debra Graves told Sydney radio station 2SER FM that most pathology labs would have to reduce the rate at which they bulk bill patients, meaning many will be forced to make a co-payment.

The issue has alarmed doctors and pathologists because of concerns that out-of-pocket costs will convince many patients to forego a pap smear, reducing the chances of early detection of cervical cancer.

AMA President Professor Brian Owler condemned the bulk billing incentive cuts at the time they were announced, describing them as “a co-payment by stealth”.

Health Minister Sussan Ley has tried to head off a social media campaign on the issue by arguing that the Government has not touched the Medicare rebate it pays for pap smear tests, and the bulk billing incentive was an “inefficient” payment to pathology companies.

In its Mid-Year Economic and Fiscal Outlook statement, the Government estimated that axing the incentive for pathology services and reducing it for diagnostic imaging would save $650 million over four years.

But the AMA said that the bulk billing incentive had been used by successive governments to help offset the fact that the Medicare rebate for pathology services including pap smears had not been increased in 17 years, and the net effect of axing the incentive was a cut in the Government’s contribution to the cost of a pap smear.

An online petition objecting to the change, which is due to come into effect from 1 July this year, has so far collected almost 34,000 signatures.

Those signing the petition claim the cuts are unfair and will lead to the late detection of illness, which would end up costing the health system more.

Professor Owler said the AMA strongly opposed the changes and would be working to convince the Senate to disallow them.

Adrian Rollins